Provider Demographics
NPI:1720330319
Name:BULLARD, LAUREN MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:MARIE
Last Name:BULLARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:MARIE
Other - Last Name:SHOEMAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1863
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:21401 ALLEN RD
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:MI
Practice Address - Zip Code:48183-1665
Practice Address - Country:US
Practice Address - Phone:734-675-0835
Practice Address - Fax:734-675-0873
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006508207N00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207N00000XAllopathic & Osteopathic PhysiciansDermatology